Panel 6

Breastmilk and transmission of HIV

Breastfeeding confers enormous benefits, preventing malnutrition and
illness, saving lives and money. It is also, however, one way an HIV-positive
mother could transmit the virus to her infant. A child stands the greatest
risk - believed to be 20 per cent - of vertical or mother-to-child transmission
during the time of late pregnancy and childbirth. There is an additional
14 per cent risk that an infant will become infected through breastmilk.

This risk of infection through breastfeeding needs to be weighed against
the great dangers posed by artificial feeding: In communities where sanitation
is inadequate and families are poor, death from diarrhoea is 14 times higher
in artificially fed infants than in those who are breastfed. If HIV-positive
women and those who fear HIV (without actually being infected) were to abandon
breastfeeding in large numbers, with out safe and reliable alternatives
for feeding their children, the ensuing infant deaths from diarrhoea and
respiratory infections could vastly outnumber those from HIV.

The dilemma facing an HIV-positive woman who does not have easy access
to safe water, who does not have enough fuel to sterilize feeding bottles
and prepare alternatives to breastmilk, or who cannot afford to buy sufficient
formula to ensure her child's nutrition is a wrenching one that no mother
can solve on her own. Support for women facing this di lem ma is imperative,
as the Joint United Nations Programme on HIV/AIDS (UNAIDS) made clear in
1996. The following measures are important starting points:

* Pregnant women should have access to voluntary and confidential counselling
and testing to determine their health status. If they are HIV positive,
they should receive appropriate treatment to reduce the risk of vertical
transmission. If they are HIV negative, health education is vital to help
them and their partners remain that way.

* HIV-positive mothers should be informed of the risks of both vertical
transmission through breastfeeding and infections associated with artificial
feeding in their local environment. Each woman should be assisted by HIV
counsellors or health professionals to understand these risks and then make
her own decision.

* If an HIV-positive mother has access to adequate breastmilk substitutes
that she can prepare safely, then she should consider artificial feeding.
Other alternatives include wet-nursing by an HIV-negative woman, which may
be acceptable in some cultures. Heat treatment of expressed breast milk
(62.5C for 30 minutes) destroys the virus, which may be a good choice for
some women.

* When mothers who test positive for HIV choose not to breastfeed but
are unable to or cannot afford feeding alternatives, help will be needed
from a range of parties, in cluding governmental and partner agencies. Attention
must be paid to the needs of the most disadvantaged women, which include
improved water and sanitation and attentive family health care.

These measures should be part of an integrated strategy to reduce vertical
transmission since breastfeeding is only a small part of the problem. Access
to voluntary, confidential testing and counselling is key to any strategy
to reduce vertical transmission. Access to a range of prenatal and obstetric
care measures associated with reduced transmission risk is also essential.

Studies now in progress will soon give a better understanding of the
mechanisms, timing and risks of vertical transmission. It may be possible
in a few years to offer all women low-cost, easily delivered services that
will minimize or even eliminate the risk of vertical transmission. For now,
access to the testing, counselling, information and other services noted
above should be high priorities.